Brendan

Amblyopia: New Treatments Pamela F. Gallin, M.D. Director, Pediatric Ophthalmology Children’s Hospital of New York Edward S. Harkness Eye Institute

IF Vision Screens were done as children THEN 2% - 5% of adults would NOT be legally blind!

Army Induction Studies

your brain (occiput) does not see What is Amblyopia? One eye is IN focus & One eye is NOT in focus your brain (occiput) does not see

Amblyopia

Normal Retina

Duke Elder Classification Amblyopia ex Anopsia Congenital (Organic) Amblyopia Strabismic Amblyopia Anisometropic Amblyopia

Amblyopia ex Anopsia (Anterior Segment) Stimulation deprivation amblyopia from lack of formation of retinal images Congenital Ptosis (lids) Corneal Opacification Congenital Cataract

2. Congenital (Organic) Amblyopia (Posterior) Seemingly undetectable lesion ...but during treatment… no visual improvement… because of retinal or visual pathway dysfunction

3. Strabismic Amblyopia Active inhibition or suppression of one retinal image by the cerebral cortex to eliminate the diplopia (double) by the deviating eye

4. Anisometropic Amblyopia Optically unmatched eyes so that one eye is in focus, and the other is not Silent Disease as least 1.5 to 2.0 diopters difference or more between the 2 eyes

Nobel Prize 1981 David Hubel Torsten Wiesel

Hubel and Wiesel 80% of occiput is binocular suture lids of one eye at birth… … small % cells binocular ... small % normal occlude one eye at birth & open at 3 months … occlude 2nd eye…..BLIND transiently some vision returns, but permanently suppressed No light to both eyes from birth… less damage

Visual Cortex Occiput

LGN involved?? 1941 Le Gros Clark Journal of Anatomy 75, 419

LGN involved

Cerebral cortical inhibition (suppression) is: an active process at the level of LGN and calcarine cortex

Amblyopia is a Silent Disease

Brendan

American Academy of Ophthalmology recommend vision screen at 3.5 years of age

Vision Screen Allen Cards E game # Slide Letters New Techniques desktop VEP

Snellen Chart

Diopsys: desktop VEP

Patient views grating and yields VEP

Diopsys Results Norm Abnl

Dilated Cycloplegic Retinoscopy Mydriacyl 1% Cyclogel 0.5%, 1%, (2%)

An unmatched set optically Right eye IN focus Then RIght eye vision Normal Left eye Not in focus Then Left eye Vision Decreased (unless intervention)

Brain shuts off image from out of focus eye Suppression Brain shuts off image from out of focus eye

So, give glasses to one eye and it will see? Yes, image will be focused on retina But, image will NOT be developed in brain Because, cortical cells are scrambled (H&W) BUT They can become functional up to 7.5 - 9 years

Exceptions: Small differences… glasses (with Rx in 1 eye) can work Large differences… need contact lens for one eye

Maintain until 9 years of age The goal is 20/25 Maintain until 9 years of age

Treatment Patching OcclusionTherapy Penalization -optical -pharmacologic Bangerter Films New Techniques

Patching (Occlusion Therapy) On face adhesives vary 1 week/year life …5 y.o. = 5 wks …1 y.o. = 1 wk

Occlusion Amblyopia

Brendan 11 months + 1.75 / - 7.00 Patch and glasses

Optical Penalization Pharmacologic atropine Optical blur good eye with out of focus lens Bangerter Film

Brendan wouldn’t wear patch and glasses So, we added Atropine under the patch

Brendan wouldn’t wear patch at all, So, in addition to the Atropine, we added Bangerter film

Bangerter Films Clear pieces of plastic (colorforms) Adjust level of blur (e.g. net vision you have) Can see large targets with both eyes Peripheral Vision INTACT Socially acceptable in elementary school!! INVISIBLE Imported from Switzerland ($2.00)

Bangerter Films

We added a contact lens with atropine in the other eye And because the difference between the 2 eye prescriptions was so high (and that is why he didn’t like the glasses) We added a contact lens with atropine in the other eye

Contact Lenses used when the differences very high after 9 years of age, when don’t want to wear glasses for one eye

After contact lenses AND 21 Consider refractive surgery e.g. Lasik and others

Brendan had High Anisometropia (8.75) glasses & patch glasses & patch & atropine glasses & patch & atropine & Bangerter film THEN contact lens & patch & atropine

We knew that: Brendan had vision 20/70…from Diopsys And that: He would be Blind in that eye IF Nothing was done

Youngest child in world October, 2002 Lasik Youngest child in world Vision 20/40!!!!! Dr. Jonathan Davidorf UCLA

Brendan began to have slight myopia and astigmatism Vision began to slip Treated like regular small anisometropia Glasses/BG film/Atropine (prn) August, 2004 Vision 20/20 right..20/50 left Age 4.5 (much room to maneuver)

October, 2004 Left Eye 20/60 January, 2005 Left Eye 20/80

Brendan

Amblyopia is a SILENT disease 2% to 5% of adult population PREVENTABLE If diagnosed EARLY by vision screens!!!

Vision Screens mandatory at 3.5 years all annual visits ? Diopsys

Treatment Glasses (if anisometropia) Occlusion = Patching Atropine Bangerter Films

contact lens (one eye) Refractive Surgery (lasik) Desperation: contact lens (one eye) Refractive Surgery (lasik)

Treatment must be continued until 9 years of age Treatment must be continued until 9 years of age! Hubel and Wiesel but, it works!!

2% - 5% of children should NOT be blind in one eye YOU CAN prevent this with a vision screen